Spiritual Direction - Care Survey and Client Agreement Form

Work with Em

Questionnaire for Spiritual Direction
About Spiritual Direction with Em
Em’s spiritual practices and training are rooted in Jewish principles of time, cycles, mysticism and relationship tending to the more than human world. With a robust set of tools for holding space for others, Em offers spiritual accompaniment to anyone in need of guidance in deepening their relationship to a higher power. With a framework of disability justice and the commitment to a liberated future for all, they bring their experiences as a spiritual leader, ritualist, herbalist, songwriter, teacher and community organizer to their work of spiritual care. Em is based on the ancestral lands of the Yuchi, Shawnee and Eastern Cherokee people in Middle Tennessee and is a non-binary white disabled person of Ashkenazi Jewish lineage. In addition to having trained with Still Harbor for spiritual direction, they are also currently enrolled in a program where they are studying davvening (the art of prayer) and prayer leading.

A spiritual director offers accompaniment of a person’s spiritual journey through presence, supportive reflections, ritual building and intuitive listening as a way of deepening our intimate relationship with Spirit, Ruach, Yah, higher power, and beyond. It is the sacred work of listening in. It is feeling into where Spirit is moving in us or what is being whispered into our hearts. While spiritual accompaniment is practiced in a one-on-one setting, it is not to be mistaken for therapy nor is it a substitute for mental health care. It is, however, a place and time for exploring your spiritual freedom and growth. Sessions range from 45 - 60 minutes and they typically occur on a monthly basis.
How to prepare for a session:
You do not need to prepare in any way except by bringing your whole self. There are no expected outcomes. There is no agenda. You may have something on your heart already, or you may wait to see what emerges. From this place, we listen deeply together to support you in your spiritual journey.

Rates:
Sliding scale $100-$150 (if cost is prohibitive, please reach out for deeper sliding scale options)

Cancelation Policy:
Canceling/rescheduling for non-emergency reasons, please notify me with 24 hours notice or pay a $50 cancelation fee.

Payments:
venmo @ everalters or paypal “friends and family” to emma.berkey at gmail dot com
Introduce Yourself
Full Name

First NameLast Name
Email Address
example@example.com
Contact Number
Please enter a valid phone number.
If you want to share, please share your pronouns:
What other aspects of your identity would you like to share that feel important to you?
What is your date of birth?

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How do you spend your days? What kind of work do you do in the world?
What do you like doing in your free time?
Please share anything about your mental, physical, or emotional health that you want me to know.
Please indicate at least three times of the week we could meet.
Emergency Contact Name
Emergency Contact Phone Number
Please enter a valid phone number.
Relationship to Emergency Contact
Inner Spiritual Journey Questions

This is an opportunity for you to share more about your inner spiritual life with me. No need to use full sentences or respond to every question. Respond in the way that feels accessible to you and to what you feel connected the most.
How would you describe your spiritual and/or religious identity? What are some of the core beliefs and tenets of your spiritual and/or religious faith? Do you have any names that you use for the Divine or G-d that feel good to you that you'd like to mention?
Describe your spiritual journey and what has led you to this point. What are some of the joys and challenges along the way?
Who is your spiritual community? Who are your teachers, and who have you learned from along the way? What lineages do you draw from? What sacred texts, art, poetry, music, etc., do you like to work with and/or inspires you?
Please briefly describe what some of your spiritual practices look like (ritual work, prayer practices, meditation, chanting, etc). What practices would you like to learn more about or develop?
Have you ever had a spiritual director? If so, what led you into that relationship and how was your experience? If not, what brings you to seek spiritual accompaniment now? Do you have any concerns about spiritual direction?
What would make this experience most accessible for you?
What themes, dreams, imagery, sounds have been coming up for you lately that feel relevant?
What else would you like share about yourself that would be helpful? (personality markers, how you process information, astrological signs, etc.)

Work with Em

About Spiritual Direction with Em

Introduce Yourself

Inner Spiritual Journey Questions

Client Agreement and Confidentiality